Symptomatic Spinal Metastases Research Articles

Patient-Reported and Clinical Outcomes of Surgically Treated Patients With Symptomatic Spinal Metastases: Results From Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO), a Prospective, Multi-Institutional and International Study.

The palliative impact of spine surgery for metastatic disease is evolving with improvements in surgical technique and multidisciplinary cancer care. The goal of this study was to prospectively evaluate long-term clinical outcomes including health-related quality-of-life (HRQOL) measures, using spine cancer-specific patient-reported-outcome (PRO) measures, in patients with symptomatic spinal metastases who underwent surgical management. The Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO, ClinicalTrials.gov identifier: NCT01825161) trial is a prospective-observational cohort study that included 10 specialist centers in North America and Europe. Patients aged 18 to 75 years who underwent surgery for spinal metastases were included. Prospective assessments included both spine tumor-specific and generic PRO tools which were collected for a minimum of 2 years post-treatment or until death. Two hundred and eighty patients (51.8% female, mean age 57.9 years) were included. At presentation, the mean Charlson Comorbidity Index was 6.0, 35.7% had neurological deficits as defined by the American Spinal Cord Injury Association scores, 47.2% had high-grade epidural spinal cord compression (2-3), and 89.6% had impending or frank instability as measured by a Spinal Instability Neoplastic Score of ≥7. The most common primary tumor sites were breast (20.2%), lung (18.8%), kidney (16.2%), and prostate (6.5%). The median overall survival postsurgery was 501 days, and the 2-year progression-free-survival rate was 38.4%. Compared with baseline, significant and durable improvements in HRQOL were observed at the 6-week, 12-week, 26-week, 1-year, and 2-year follow-up assessments from a battery of PRO questionnaires including the spine cancer-specific, validated, Spine Oncology Study Group Outcomes Questionnaire v2.0, the Short Form 36 version 2, EuroQol-5 Dimension (3L), and pain numerical rating scale score. Multi-institutional, prospective-outcomes data confirm that surgical decompression and/or stabilization provides meaningful and durable improvements in multiple HRQOL domains, including spine-specific outcomes based on the Spine Oncology Study Group Outcomes Questionnaire v2.0, for patients with metastatic spine disease.

Predictive Modeling for Spinal Metastatic Disease.

Spinal metastasis is exceedingly common in patients with cancer and its prevalence is expected to increase. Surgical management of symptomatic spinal metastasis is indicated for pain relief, preservation or restoration of neurologic function, and mechanical stability. The overall prognosis is a major driver of treatment decisions; however, clinicians' ability to accurately predict survival is limited. In this narrative review, we first discuss the NOMS decision framework used to guide decision making in the treatment of patients with spinal metastasis. Given that decision making hinges on prognosis, multiple scoring systems have been developed over the last three decades to predict survival in patients with spinal metastasis; these systems have largely been developed using expert opinions or regression modeling. Although these tools have provided significant advances in our ability to predict prognosis, their utility is limited by the relative lack of patient-specific survival probability. Machine learning models have been developed in recent years to close this gap. Employing a greater number of features compared to models developed with conventional statistics, machine learning algorithms have been reported to predict 30-day, 6-week, 90-day, and 1-year mortality in spinal metastatic disease with excellent discrimination. These models are well calibrated and have been externally validated with domestic and international independent cohorts. Despite hypothesized and realized limitations, the role of machine learning methodology in predicting outcomes in spinal metastatic disease is likely to grow.

Optimizing outcomes in symptomatic spinal metastases from non-small cell lung cancer: Evaluating the role of salvage surgical intervention in a multidisciplinary context – A Narrative Review

Background: Lung cancer, a leading cause of cancer-related mortality worldwide, often metastasises to the spine, resulting in significant morbidity and complex treatment challenges. The management of spinal metastatic disease from lung cancer necessitates a multidisciplinary approach, given the array of potential interventions including surgery, radiation therapy, chemotherapy, and supportive care. The selection of appropriate therapeutic strategies is influenced by multiple factors, including disease staging, patient health status, and symptomatology. Aim: This review article aims to explore the current landscape of surgical intervention for spinal metastases from lung cancer, evaluating its role, efficacy, and the criteria for patient selection within the context of multidisciplinary care. Additionally, it seeks to provide an overview of the existing treatment modalities, highlighting the importance of a tailored approach based on individual patient needs. Methods: An extensive review of the literature was conducted, focusing on studies, clinical trials, and meta-analyses published on the treatment of spinal metastases in lung cancer patients. Special attention was given to works discussing the surgical outcomes, prognostic factors, and the evolution of treatment protocols over recent decades. Results: Surgical treatment for spinal metastases from lung cancer is beneficial for select patients, particularly those without prior systemic treatments and those in good overall health. The decision to pursue surgery should be made within a multidisciplinary team, taking into account the patient’s specific situation and potential to benefit from the intervention. Research advancements and technological innovations continue to refine surgical techniques and improve patient outcomes. Conclusion: While the role of surgery in treating spinal metastatic disease from lung cancer is limited, it remains a critical option for appropriately selected patients. Future research should aim to further define and expand the criteria for surgical candidacy, enhancing the precision of patient selection and tailoring of treatment strategies. Emphasis on a multidisciplinary approach is essential for optimising outcomes and advancing care for patients with this challenging condition.

A critical appraisal of clinical practice guidelines on surgical treatments for spinal metastasis.

As an important treatment for spinal metastasis, surgery has strict applicable conditions. Although various organizations have formulated different guidelines on surgical treatment for spinal metastasis (SM), there are certain differences in the content, standardization and quality of the guidelines and it is necessary to make a critical appraisal of them. We aim to systematically review and appraise the current guidelines on surgical treatments of SM and summarize the related recommendations with the quality evaluation of supporting evidence, as to provide a reference for the standardization of surgical treatment plans, and help clinical front-line medical workers can make safe and effective clinical decisions faster. We searched Pubmed, Web of Science, and Embase for three major databases and online guideline databases. According to certain inclusion and exclusion criteria, the latest guidelines on the surgical treatment of SM were sorted out. AGREE II was used to evaluated the guideline's quality, and we extracted and compared the recommended treatment content of each guideline with evaluating by the evidence-grading scale. Eight guidelines from 2013 to 2019 were included. Seven guidelines are comprehensive guidelines and one related to the reconstructive surgery of SM. Five guidelines were evaluated as "recommended," and three guidelines were evaluated as "recommended with modifications." Regarding the indications of surgery with SM, four guidelines, seven guidelines, seven guidelines, three guidelines and three guidelines recommended surgical treatment for patients with SM with intractable pain, mechanical instability, metastatic epidural spinal cord compression (MESCC), recurrent spinal metastasis (RSM), and survival predication, respectively. Regarding the surgical strategies, three guidelines recommended minimally invasive therapy but had strict indications. Six guidelines and five guidelines recommend palliative surgery and with receiving radiation therapy, respectively. For the aggressive surgery, only one guideline recommended to apply to patients in good general conditions who has isolated symptomatic SM. Regarding the surgical reconstructions, one guideline didn't recommend iliac bone graft and three guidelines recommended PMMA bone cement. Most of the guidelines do not provide clear criteria for surgical application and provide more of a basic framework. The level of evidence for these surgical recommendations ranges from LOE B to D, and almost all guidelines recommend vertebroplasty and kyphoplasty, but for palliative and more aggressive surgery, which recommended to personalize specific surgical strategies with multidisciplinary collaboration.

Safety and feasibility of ultra-long construct navigated minimally invasive spine surgery with adjuvant radiotherapy in extensive spinal metastasis : a comparative analysis

BackgroundOur study compares the outcomes of extensive spinal metastasis patients treated with Ultra-Long Construct Navigated Minimally Invasive Spine Surgery (UNMISS) with Adjuvant Radiotherapy to those receiving only radiotherapy. Spinal metastasis often necessitates interventions like radiotherapy, chemotherapy, or surgery, with an increasing trend towards surgical management. minimally invasive spine surgery has demonstrated advantages over traditional open surgery, with fewer complications and better postoperative outcomes. Radiotherapy continues as a standard for those unsuitable for surgery.MethodsThis retrospective study included extensive spinal metastasis patients treated between January 2017 and December 2020. We compared patients undergoing UNMISS in conjunction with radiotherapy to patients receiving radiotherapy alone, evaluating demographic data, disease characteristics, and treatment outcomes (VAS, survival) to establish statistical significance.ResultsTwenty-three patients were included in our study. Fourteen patients underwent UNMISS, and nine patients received radiotherapy alone. There was no difference in baseline characteristics of patients. The longest construct in our case series involved T1 to iliac. Both cohorts showed significant improvement in pain scores post-treatment (p = 0.01). However, the UNMISS group demonstrated significantly lower post-treatment VAS scores (p = 0.003), indicating enhanced pain relief. Survival outcomes did not differ significantly between the two groups.ConclusionThe UNMISS should be considered as an alternative treatment in a patient with symptomatic extensive spinal metastasis. The primary goal of this technique is to stabilize the multiple levels of spinal metastasis and decompression of the neural element if needed. This technique is safe and has a better outcome in pain improvement than the patient who received radiotherapy alone.

The Identification of Risk Factors for Symptomatic Spinal Metastasis Onset: A Prospective Cohort Study of 128 Asymptomatic Spinal Metastasis Patients.

Background: Symptomatic spinal metastasis (SSM) decreases the activities of daily living (ADL) and quality of life of cancer patients. However, the risk factors for SSM onset remain unclear. This prospective cohort study aimed to statistically analyze the significant risk factors. Methods: From 2016 to 2018, 210 consecutive patients with spinal metastases were prospectively registered. Patients with SSM at the first consultation and those who were unable to be followed-up owing to poor general condition were excluded. The demographic factors (age, sex, primary cancer, performance status, and ADL), clinical factors (radiation therapy, chemotherapy, molecularly targeted drugs, and bone-modifying agents (BMAs)), and Spinal Neoplastic Instability Score (SINS) were evaluated. Multivariate analysis was performed to identify the risk factors for SSM onset. Furthermore, the threshold was calculated from the receiver operating characteristic curve using the Youden index. Results: Thirty-nine patients who presented with SSM at the first consultation and 43 patients who were unable to be followed-up owing to poor general condition were excluded. Finally, 128 asymptomatic patients were included. Thirty-seven patients (28.9%) developed SSM during the follow-up period. The total SINS (OR: 1.739; 95% CI: 1.345-2.250) was identified as the most significant factor. The cut-off value of the SINS was 9.5 (sensitivity: 67.6%; specificity: 83.5%). Twenty-five (62.5%) of the forty patients with a SINS ≥ 10 developed SSM within a mean of 5.5 months (95% CI: 1.17-9.83). Furthermore, all patients with a SINS ≥ 13 developed SSM (n = 5) within a mean of 1.37 months (95% CI: 0.0-3.01). Conclusions: This study identified the significant risk factors for SSM onset and the threshold of the SINS. If long-term survival is expected, patients with a SINS ≥ 10 should be considered for intervention to prevent SSM.

Translation and validation of the Dutch Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) to evaluate health-related quality of life in patients with symptomatic spinal metastases

BackgroundThe primary goal of palliative treatment of spinal metastases is to maintain or improve health-related quality of life (HRQOL). We translated and validated a Dutch version of The Spine Oncology Study Group Outcome Questionnaire (SOSGOQ2.0), a valid and reliable 20-item questionnaire to evaluate HRQOL in patients with spinal metastases.MethodsAfter cross-cultural translation and adaptation, the questionnaire was pre-tested in fifteen patients referred for spine surgery and/or radiotherapy. This resulted in a final questionnaire that was sent to patients for assessment of internal consistency, construct (i.e., convergent and divergent) validity, discriminative power and test-retest reliability.ResultsOverall, 147 patients (mean age 65.6 years, SD = 10.4) completed the questionnaire after a median time of 45.4 months (IQR = 18.9–72.9) after spine surgery and/or radiotherapy. Internal consistency was good for the Physical function, Pain, and Mental health domains (α = 0.87, 0.86, 0.72), but not for Social function (α = 0.04). Good convergent validity was demonstrated except for Social function (rs = 0.37 95%CI = 0.21–0.51). Discriminative power between patients with ECOG performance scores of 0–1 and 2–4 was found on all domains and Neurological function items. Test-retest reliability was acceptable for Physical function, Pain and Mental health (ICC = 0.89 95%CI = 0.81–0.94, ICC = 0.88 95%CI = 0.78–0.93, ICC = 0.68 95%CI = 0.48–0.81), whereas ICC = 0.45 (95%CI = 0.17–0.66) for Social function was below threshold. After removing item 20 from the Social function domain, internal consistency improved, and convergent validity and test-retest reliability were good.ConclusionThe Dutch version of the SOSGOQ2.0 questionnaire is a reliable and valid tool to measure HRQOL in patients with spinal metastases. Item 20 was removed to retain psychometric properties.

Survival Rate after Palliative Surgery Alone for Symptomatic Spinal Metastases: A Prospective Cohort Study.

The effect of spine surgery for symptomatic spinal metastases (SSM) on patient prognosis remains unclear. This study aimed to reveal the prognosis of patients with SSM after spine surgery. One hundred twenty-two patients with SSM were enrolled in this prospective cohort study. The patients who received chemotherapy after enrollment were excluded. The decision of surgery depended on patient's willingness; the final cohort comprised 31 and 24 patients in the surgery and non-surgery groups, respectively. The patients were evaluated by their performance status (PS), activities of daily living (ADL) and ambulatory status. Survival was evaluated by the Kaplan-Meier method. The PS, ADL and ambulation were significantly improved in the surgery group compared to non-surgery group. The median survival was significantly longer in the surgery group (5.17 months, 95% confidence interval (CI) 3.27 to 7.07) than in the non-surgery group (2.23 months, 95% CI 2.03 to 2.43; p = 0.003). Furthermore, the patients with a better PS, ADL and ambulatory status had a significantly longer survival. Surgery improved the PS, ADL, ambulation and survival of patients with SSM. In the management of SSM, spine surgery is not only palliative but may also prolong survival.

The Changing Landscape for the Treatment of Painful Spinal Metastases: is Stereotactic Body Radiation Therapy the New Standard of Care?

Due to advancements in systemic targeted and immunotherapies resulting in improved disease control and overall survival, and the increasing use of computed tomography and spine magnetic resonance imaging surveillance, the number of patients presenting with both asymptomatic and symptomatic spinal metastases is increasing. The need for versatile tumour ablative local management strategies, beyond the limits afforded by conventional palliative external beam radiation therapy (cEBRT), is increasingly more important. Stereotactic body radiation therapy (SBRT) was developed to meet such a need. This highly conformal technique allows the delivery of high biologically effective doses of radiation to the vertebral target, while controlling the differential dose exposure to the adjacent critical neural tissue. Identifying patients with painful spine metastases who would gain the most benefit from this important therapeutic option can be challenging. Here we summarise the randomised evidence specific to spine SBRT, comparing cEBRT with SBRT for pain control in patients with spine metastases in the palliative setting to better understand the role of spine SBRT in modern oncological spinal care.

New, innovative prognosis calculator for patients with metastatic spinal tumors

The aim of our research was to create a scoring system that predicts prognosis and recommends therapeutic options for patients with metastatic spine tumor. Increasing oncological treatment opportunities and prolonged survival have led to a growing need to address clinical symptoms caused by meta-stases of the primary tumor. Spinal metastases can cause a significant reduction in quality of life due to the caused neurological deficits. A scoring system that predicts prognosis with sufficient accuracy could help us to achieve personalised treatment options. Methods - We performed a retrospective clinical research of data from patients over 18 years of age who underwent surgery due to symptomatic spinal metastasis at the National Institute of Mental Disorders, Neurology and Neurosurgery between 2008 and 2018. Data from 454 patients were analysed. Survival analysis (Kaplan-Meier, log-rank, Cox model) was performed, network science-based correlation analysis was used to select the proper prognostic factors of our scoring system, such that its C value (predictive ability index) was maximized. Multivariate Cox analysis resulted in the identification of 5 independent prognostic factors (primary tumour type, age, ambulatory status, internal organ metastases, serum protein level). Our system predicted with an average accuracy of 70.6% over the 10-year study period. Our large case series of surgical dataset of patients with symptomatic spinal metastasis was used to create a risk calculator system that can help in the choice of therapy. Our risk calculator is also available online at https://emk.semmelweis.hu/gerincmet.

The role of mini-invasive surgery (MIS) in symptomatic spinal metastases

The role of mini-invasive surgery (MIS) in symptomatic spinal metastases

The Oswestry Spinal Risk Index (OSRI) in assessing prognosis of patients with spinal metastases

IntroductionThe Oswestry Spinal Risk Index (OSRI) was designed to predict life expectancy of patients presenting with spinal metastases. It integrates the most predictive items of existing scores and is calculated using not more than two items: General condition and primary tumor. Research questionThe purpose of this study was to externally validate the OSRI in a large cohort and to compare it with the established scores. Material and methodsWe retrospectively identified 211 consecutive surgical patients with symptomatic spinal metastases. We collected clinical and radiographic data, such as Karnofsky Performance Score (KPS), Frankel Status, primary tumor pathology and metastatic spread to calculate the Tokuhashi score, Tomita score, modified Bauer score and the OSRI. Logistic regression models, Kaplan-Meyer-curves, discriminant power and variance analyses were applied using Harrell’s C-index and Cox and Snell’s Pseudo R². ResultsPredicted and actual survival of our cohort’s patients correlated significantly in each investigated scoring systems (p < 0.001). In test quality measurements Tokuhashi score performed best (C = 0.7204; R² = 0.3619), followed by OSRI (C = 0.7023; R² = 0.2612), Tomita (C = 0.6748; R² = 0.2818) and modified Bauer score (C = 0.6653; R² = 0.2486). Accuracy of predicted life expectancy was highest in modified Bauer score and OSRI. Discussion and conclusionCompared to the original scores, the OSRI provided equal or even superior results in assessing our study population’s life expectancy. Its particular advantage lies in the simplicity of its application, which well meets the demands of surgical decision-making in daily practice.

Surgical Management Update in Metastatic Disease of the Spine

Approximately 12%-20% of patients with metastatic disease will initially present with symptomatic spinal metastasis. Treatment goals include pain control, spinal stability, recovery of neurologic function, local tumor control through debulking or tumor excision, and improved quality of life. Treatment options depend on several factors: spinal stability, patient health and comorbidities, clinical presentation, prognosis, life expectancy, and tumor histology. The following chapter reviews classification of metastatic spinal diseases and the various options, techniques, and reported outcomes for surgical management.

Identifying new predictive factors for survival after surgery for spinal metastases: an exploratory in-depth retrospective analysis

ABSTRACT Objectives In selected patients with symptomatic spinal metastasis from solid tumors, surgery improves quality of life. Since selection is key, inaccurate survival prognostication may result in poor decisions and outcomes. However, most prognostic scores suffer from suboptimal external validation and subsequent mediocre performance. This warrants the ongoing search for factors that better capture the oncological status. This exploratory study aims to identify new preoperative variables that predict survival. Methods A retrospective analysis was conducted on 62 patients from a tertiary care referral center who underwent debulking and/or reconstruction surgery for spinal metastases between 2006 and 2018, and in whom detailed clinical, oncological, surgical and biochemical variables were collected. Univariate and multivariate analyses were performed for overall survival. Results Median survival was 13.2 months. Multivariate analysis for overall survival identified that a higher number of organs with metastases, a shorter time to progression on the last line of systemic therapy before surgery (TTPbs), low serum albumin, high alkaline phosphatase, high C-reactive peptide (CRP), presence of brain metastasis and the index spinal level located in the cervical region were independently associated with shorter survival. Conclusion We confirmed previously known predictors and identified CRP and TTPbs as new variables that were strongly associated with survival. The latter variable may replace primary tumor type, as improved cancer treatments make the primary tumor type less relevant as a predictor. This study is exploratory and its findings need to be validated, preferably in large prospective multicenter studies that are aiming at improving existing models.

Guidelines for Palliative Treatment of Spinal Metastases: Choosing Between Stereotactic Body Radiation Therapy and Conventional Fractionation

Symptomatic spinal metastasis is a frequent complication of cancer that had been treated, until relatively recently, with primitive techniques to modest radiation dose levels, with a baseline assumption of limited survival and poor patient performance in that setting. In the era of targeted and personalized therapies, many patients are living longer and more functionally and are able to manage their disease on the model of chronic illness. Given these developments, an attractive option is the use of stereotactic body radiation therapy (SBRT) to deliver high biologically effective doses of radiation conformally to maximize the palliative gains of treatment. However, randomized data to guide practice are scarce. We review the extant literature and present an algorithmic approach to selecting patients with metastatic disease for palliative spinal SBRT favoring the results of available randomized studies and remaining within the safety constraints supported by evidence from randomized trials.

Analysis of unplanned hospital readmissions up to 2-years after metastatic spine tumour surgery.

The aim of this study was to investigate rates, causes, and risk factors of unplanned hospital readmissions (UHR) within 30 days, 90 days, 1 year and 2 years after metastatic spine tumour surgery (MSTS) to augment multi-disciplinary treatment planning and improve patient education. We retrospectively reviewed 272-patients who underwent MSTS between 2005 and 2016. Hospital records were utilised to obtain demographics, oncological, procedural details, and postoperative outcomes. All UHR within 2 years were reviewed. Primary outcomes were rates, causes, and risk factors of UHR. Risk factors for UHR were evaluated utilising multivariate logistic regression analysis. Thirty-day, 90 day, 1 year, and 2 year UHR-rates after MSTS were 17.2%, 31.1%, 46.2%, and 52.7%, respectively. Lung cancer primaries had the highest UHR-events (24.7%) whilst renal/thyroid displayed the least (6.6%). Disease-related causes (16.2%) were the most common reason for readmissions across all timeframes, followed by respiratory (13.7%) and progression of metastatic spine disease (12.7%). Urological conditions accounted for majority of readmissions within 30-days; disease-related causes, symptomatic spinal metastases, and respiratory conditions represented the most common causes at 30-90 days, 90 days-1 year, and 1-2 years, respectively. An ECOG >1 (p=0.057), CCI >7 (p=0.01), and primary lung tumour (p=0.02) significantly increased UHR-risk on multivariate analysis. Seventy-four percent of patients had at least one UHR within 2 years of MSTS and majority were secondary to disease-related causes. Majority of first UHR occurred between 30 and 90 days post-surgery. Local disease progression and overall disease progression account for the highest UHR-events at 90 days-1 year and 1-2 year timeframes, respectively. We define UHR in specific timeframes, thus enabling better surveillance and reducing unnecessary morbidity.

Predicting postoperative quality-of-life outcomes in patients with metastatic spine disease: who benefits?

Symptomatic spinal metastasis occurs in around 10% of all cancer patients, 5%-10% of whom will require operative management. While postoperative survival has been extensively evaluated, postoperative health-related quality-of-life (HRQOL) outcomes have remained relatively understudied. Available tools that measure HRQOL are heterogeneous and may emphasize different aspects of HRQOL. The authors of this paper recommend the use of the EQ-5D and Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ), given their extensive validation, to capture the QOL effects of systemic disease and spine metastases. Recent studies have identified preoperative QOL, baseline functional status, and neurological function as potential predictors of postoperative QOL outcomes, but heterogeneity across studies limits the ability to derive meaningful conclusions from the data. Future development of a valid and reliable prognostic model will likely require the application of a standardized protocol in the context of a multicenter study design.

The importance of timely treatment for quality of life and survival in patients with symptomatic spinal metastases

PurposeA major challenge in metastatic spinal disease is timely identification of patients. Left untreated, spinal metastases may lead to gross mechanical instability and/or neurological deficits, often requiring extensive invasive surgical treatment. The aim of this cohort study was to assess the correlation between delayed treatment of patients with spinal metastases and functional performance, quality of life and survival.MethodsAll patients surgically treated for metastatic spinal disease at a tertiary care facility were included for analysis. Patients who underwent elective surgery were considered as timely treated, whereas patients requiring emergency surgery were considered to be treated in a delayed fashion. EQ-5D scores, KPS scores and mortality rates were compared between the two groups.ResultsA total of 317 patients (215 timely treated, 102 delayed) had survivorship data available and 202 patients (147 timely treated, 55 delayed) had clinical data available. Multivariate analyses showed delayed treatment was associated with lower EQ-5D and KPS scores and higher mortality rates, independent of confounders such as baseline EQ-5D/KPS scores, neurological status, tumor prognosis and patient age.ConclusionsThe results from the present study show delayed treatment of patients with symptomatic spinal metastases has both direct and indirect adverse consequences for functional performance status, quality of life and survival. Optimization of referral pattern may accelerate the time to surgical treatment, potentially leading to better quality of life and survival.

Predictive factors of the 30-day mortality after surgery for spinal metastasis: Analysis of a nationwide database

BackgroundSurgical procedure for symptomatic spinal metastasis is expected to improve the quality of life. Factors related to short-term perioperative mortality after surgery for spinal metastasis may be different from those related to long-term mortality, which have classically been used to determine the indication for surgery. The purposes of this study were to evaluate factors related to the 30-day mortality after surgery for spinal metastasis and create an integer risk scoring system. MethodsUsing the Diagnosis Procedure Combination database from 2010 to 2016, we extracted data of patients who underwent surgical procedure for spinal metastasis. Multivariable logistic regression analysis was performed to clarify the association between patient backgrounds and the 30-day postoperative mortality. We created a risk scoring system using regression coefficients to estimate the 30-day mortality for each patient. ResultsAmong 3524 patients, the 30-day mortality was 2.6%. Factors associated with a higher 30-day mortality were male sex (odds ratio, 2.50 [95% confidence interval, 1.45–4.31]), emergency admission (1.80 [1.11–2.92]), rapid growth tumors (3.83 [2.49–5.90]), and non-skeletal metastasis (2.27 [1.42–3.64]). In patients with the maximum risk score of five, the 30-day mortality was 16.2%. ConclusionsFactors related to the 30-day mortality were male sex, emergency admission, rapid growth tumors, and non-skeletal metastasis. These findings provide spine surgeons and patients knowledge of the potential risk of short-term perioperative mortality and allow them to consider the risk of surgery.

Is minimally-invasive spinal surgery a reliable treatment option in symptomatic spinal metastasis?

Up to 70% of patients with cancer are likely to develop spine metastasis. Radiation therapy is the standard of care for painful spinal metastases in absence of unstable or impending fractures. More frequently these patients require open palliative surgery for pain, vertebral collapse and neurological deficits. Minimally Invasive Spine Surgery (MISS) techniques using percutaneous pedicle screw fixation may be considered as an alternative to open surgery in selected cases. MISS techniques are thought to be associated with fewer tissues damages resulting in early pain relief, they also allow for early mobilization and optimization of function. From 2011 to 2018, 52 patients affected by spinal metastasis were treated with MISS techniques in Rizzoli Orthopaedic Institute of Bologna and in Cisanello Hospital of Pisa, Italy. All patients underwent percutaneous pedicle screw fixations (PPSF) coupled with mini-decompressions in case it was required by spinal cord compressions. All patients were evaluated pre and post-operatively by Frenkel classification and VAS scores. Mean follow-up time was 19,4 months. Preoperatively, Frankel scores were E in 37 patients, D3 in 6 patients, D2 in 3 cases, D1 in 3 patients, B in one patient and C in two. The Frankel score improved in 10 patients, remained stable in 40 patients and worsened in two patients. Preoperatively, the mean VAS score in 29 patients treated with PPSF procedure with spinal decompression was 7, while postoperatively, it became 5. In 23 patients who underwent only PPSF procedure without spinal decompression mean VAS score was 5, postoperatively it became 3. In selected cases, MISS surgeries may be considered as a valid alternative to open surgery. Although the efficacy of PPSF has been well documented in trauma or degenerative spine surgery, there is not sufficient literature about MISS techniques in spinal metastasis and further studies are needed to elucidate the most appropriate patient in which this approach could represent the gold standard of treatment.